Clinical Neurology and Neurosurgery 139 (2015) 295301

Contents lists available at ScienceDirect

Clinical Neurology and Neurosurgery

journal homepage: www.elsevier.com/locate/clineuro

Sagittal alignment of the spine: What do you need to know?

Bassel G. Diebo , Jeffrey J. Varghese, Renaud Lafage, Frank J. Schwab, Virginie Lafage
Hospital for Special Surgery, New York, NY, 10021, USA

a r t i c l e i n f o a b s t r a c t

Article history: Sagittal alignment, often misrepresented as sagittal balance, describes the ideal and normal alignment
Received 29 September 2015 in the sagittal plane, resulting from the interplay between various organic factors. Any pathology that
Accepted 18 October 2015 alters this equilibrium instigates sagittal malalignment and its compensatory mechanisms. As a result,
Available online 28 October 2015
sagittal malalignment is not limited to adult spinal deformity; its pervasiveness extends through most
spinal disorders. While further research is developing, the literature reports clinically relevant radio-
Keywords:
graphic parameters that have signicant relationships with patient-reported outcomes. This article aims
Sagittal alignment
to provide a pragmatic review of sagittal plane analysis. At the end of this review, the reader should be able
Sagittal balance
Pelvic parameters
to analyze the sagittal plane of the spine, identify compensatory mechanisms, and choose patient-specic
SRS-Schwab classication alignment targets.
2015 Elsevier B.V. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
2. Sagittal radiographic parameters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
2.1. Pelvic to spine concept . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
2.2. Cervical spine assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
2.3. Global spinal alignment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
2.4. Beyond the spine; lower limbs parameters and horizontal gaze . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
3. Applicability of sagittal plane analysis in clinical practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
3.1. Sagittal alignment is not restricted to deformity patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
3.2. Why? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
3.3. How to respect the sagittal plane when managing patients, where to start from? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
3.3.1. Proper imaging and standardized positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
3.3.2. Assessment of the spino-pelvic harmony; PI minus LL mismatch concept . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
3.3.3. Analysis of compensatory mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
3.4. Why is that signicant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
3.4.1. Global spinal alignment and gaze assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
4. Sagittal alignment targets: an update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300

1. Introduction

The human spine is a biomechanical masterpiece, enabling

bipedalism through unique skeletal alterations and resulting in
the S-shape spinal curvature. For instance, the lumbar curvature
Corresponding author at: Hospital for Special Surgery, 535 East 70th Street, New deliberately maintains the center of gravity over a narrow area
York, NY, 10021, USA. between the feet, maximizing energy efciency while minimizing
E-mail address: diebob@HSS.EDU (B.G. Diebo). the effect of gravity on joints, muscles, and ligaments.

http://dx.doi.org/10.1016/j.clineuro.2015.10.024
0303-8467/ 2015 Elsevier B.V. All rights reserved.
296 B.G. Diebo et al. / Clinical Neurology and Neurosurgery 139 (2015) 295301

Fig. 1. Pelvic radiographic parameters.

Longstanding investigations on spinal evolution, function, and

pathology have renewed a desire to study sagittal spino-pelvic
alignment. Focused research has recently converted theoretical
concepts into clinically relevant guidelines, establishing the role
of sagittal alignment in treatment of various spectrums of spinal
pathologies.
Sagittal alignment, often misrepresented as sagittal balance,
describes the ideal and normal alignment in the sagittal plane,
resulting from the interplay between various organic factors. Any
pathology that alters this equilibrium instigates sagittal malalign-
ment and its compensatory mechanisms. As a result, sagittal
malalignment is not limited to adult spinal deformity; its per-
vasiveness extends through most spinal disorders. With this in
consideration, sagittal malalignment is not a sole indication for
surgery. However, the systematic assessment of sagittal plane is
essential in evaluating the burden of spinal diseases on our patients.
This article aims to provide a pragmatic review of the most clin-
ically relevant sagittal radiographic parameters in the literature. At
the end of this review, the reader should be able to analyze the sag-
ittal plane of the spine, identify compensatory mechanisms, and
choose patient-specic alignment targets.

2. Sagittal radiographic parameters

2.1. Pelvic to spine concept Fig. 2. Spino-pelvic matching concept.

The pelvis is the cornerstone of spinal sagittal alignment. Jean

Duboussets revolutionary concept that the entire pelvis is a
vertebra triggered numerous investigations on the relationship
between pelvic morphology and spinal sagittal alignment. Ginette
Duval-Beauperes work [1,2] identied three geometrically inter-
related pelvic parameters: pelvic incidence (PI), pelvic tilt (PT), and
sacral slope (SS); where PI = PT + SS.
Because of the limited mobility of the sacroiliac joint, pelvic inci-
dence is a xed anatomical parameter dened as the angle between
the perpendicular to the S1 sacral endplate and the line from the
center of the femoral heads to the mid-point of the S1 sacral end-
plate. Pelvic tilt is dened as the angle between the vertical and
a line from the center of the femoral heads to the midpoint of the
sacral endplate. PT quanties the pelvic rotation around the femoral
heads, an established compensatory mechanism for spinal posi-
tive malalignment. Sacral Slope is dened as the angle between the
horizontal and the S1 sacral endplate [2,3] (Fig. 1).
The slope of the sacrum sets the stage for the lumbar curve; a
horizontal sacral plate (i.e. small SS) is associated with a small LL.
However, SS is positionally dependent and altered in malaligned
patients due to pelvic retroversion (increase in PT). Thus SS is
unsuitable to guide planning of surgical malalignment correction.
PI, however, is a morphological parameter that is unique to each
individual and has a strong, positive correlation with LL [4]. A new
parameter relating PI with LL has emerged to guide surgical plan-
ning and enable a patient-specic approach to treatment goals.
This novel parameter, PI minus () LL, quanties the mismatch
between pelvic morphology and the lumbar curve. Using the PI-
LL construct, a PI-LL <10 threshold was identied as a spino-pelvic
sagittal alignment goal [5] (Fig. 2).
While multiple studies have validated the PI-LL parameter [57],
simplifying the problem to a unique match between the pelvic
incidence and the lumbar lordosis is an over simplication of the
problem. For example, in cases of rigid hyper kyphosis with no
intention to reduce the large curvature, the lordosis needs to take in
account both, the pelvic and the thoracic shape. A recent study by
Schwab et al. proposed a ne-tuned formula, LL = (PI + TK)/2 + 10,
developed by multi-linear regression analysis and validated on a
separate group of subjects. This formula highlights the signicance
of artfully relating the different parameters to paint a truer picture
of sagittal alignment [8].
Regional spinal curvatures are quantied using the Cobb
method, which was rst proposed by John Robert Cobb in 1948 [9].
The Cobb method measures subject-specic maximum curvatures
by measuring the angle of the endplates between the two ends of
the regional spinal curve [10]. Although not a full characterization
of sagittal lordosis, for standardization, the lumbar curvature, i.e.
lumbar lordosis angle (LL), is measured as the angle between the
upper endplate of L1 and the sacral endplate (S1). Thoracic Kypho-
sis (TK) is similarly quantied and is dened as the angle between
the T4 upper endplate and the T12 lower endplate (Fig. 3).
Theoretically, in the sagittal plane, each parameter or curve
should ideally be within its respective normative range. This only
 B.G. Diebo et al. / Clinical Neurology and Neurosurgery 139 (2015) 295301 297

Fig. 3. Spinal radiographic parameters and chin brow vertical angle.

occurs when looking at each parameter individually and not in the

context of each other. When this normative range is expanded to
cover several parameters, the range becomes too broad to be use-
ful [4,11,12]. However, by utilizing chains of correlations quantied
by aforementioned formulas, the pelvic parameters together with
its spinal counterparts can be analyzed, yielding demographic- and
pathology-specic patterns practical in patient-specic treatment
goals.

2.2. Cervical spine assessment

Recent interest in the sagittal alignment of the cervical spine has

introduced new measures that include dynamic and focal param-
eters. However, classic measures, such as the Cervical Sagittal
Vertical Axis (cSVA), continue to quantify the regional alignment of
the cervical spine and is dened as the sagittal offset of a plumb line
dropped from the center of C2 from the posterior superior aspect
of C7. Correspondingly, C2C7 cervical curvature (CC) is dened as
the angle between the sacral endplates of C2 and C7. Classically,
a lordotic C2C7 curvature is widely accepted as normal align-
ment. However, work by Faline et al. and more recently Le Huec
et al. demonstrated the prevalence of kyphotic cervical curvature
in healthy population [13,14].

2.3. Global spinal alignment

Taking one step back from regional spinal curvatures, global

alignment can be measured to assess spinal alignment as a whole.
Global alignment is most commonly quantied by measuring the
sagittal vertical axis (SVA). It is dened as the sagittal offset of a
plumb line dropped from the C7 vertebral body from the postero-
superior corner of the sacral plate. Similarly to cSVA, a SVA above,
within, or below the acceptable range categorizes cervical align-
ment into positive, neutral, and negative alignment, respectively.
SVAs sensitivity to sagittal malalignment and its fairly unambigu-
ous categorical designations facilitates its usefulness in clinical Fig. 4. Sagittal vertical axis (SVA).
practice. The one important caveat to consider is that SVA is affected
by patient position and pelvic rotation (Fig. 4).
298 B.G. Diebo et al. / Clinical Neurology and Neurosurgery 139 (2015) 295301
Fig. 5. Lower limbs radiographic parameters.
2.4. Beyond the spine; lower limbs parameters and horizontal
gaze
Assessment of the lower limbs is part of a full body sagittal
plane analysis. Two such examples are the knee exion angle
and pelvic shift. Knee angle is dened as the angle between the
mechanical axis of the femur and the mechanical axis of the tibia.
Since the pelvic-femoral interface is a load bearing rotational axis
for the pelvis, evaluating of KA quanties knee compensation to
spino-pelvic malalignment [15]. Pelvis shift is utilized to further
quantify the compensatory mechanisms resulting from sagittal
plane malalignment [16,17]. It is dened by the sagittal offset of
the plumb line dropped from posterior superior aspect of S1 from
the anterior cortex of the distal tibia (Fig. 5).
Finally, it is important to quantify the orientation of the skull
and the ability to maintain horizontal gaze. For this purpose, chin
brow vertical angle (CBVA) has been recently emphasized as part of
sagittal plane analysis. It is dened by the angle between the ver-
tical and the line drawn from the chin to the brow. Since the CBVA
was originally developed from clinical photographs, radiological
substitutes with strong correlations to CBVA were established as
an alternative.
3. Applicability of sagittal plane analysis in clinical practice
3.1. Sagittal alignment is not restricted to deformity patients
In line with the growing interest of analyzing the sagittal
plane, there is another growing concern about the applicability of
this analysis in daily practice, especially for clinicians who deal
with non-deformity patients. However, the literature reports the
pervasive involvement of sagittal alignment in numerous spinal
pathologies, such as degenerative disc disease, osteoporosis, arthri-
tis and low back pain. Respecting the sagittal plane is not restricted
to major deformity procedures, but should also be considered even
in minor interventions on one vertebral level.
3.2. Why?
Sagittal malalignment is closely related to quality of life scores
and is a pain/disability generator. Several studies have described
the relationship between sagittal radiographic parameters and
Health Related Quality of Life (HRQOL) scores, and further detailed
the improvement in patient-reported outcomes and the substan-
tial clinical benets of improving the sagittal parameters [7,1825].
On the other hand, patients with sagittal abnormalities showed
a signicant increase in adjacent segment disease following their
surgical treatment for degenerative disc disease[26]. The relevancy
of sagittal alignment in management of osteoporotic patients has
been recently investigated. Miyakoshi et al. showed that improve-
ment of sagittal alignment in osteoporotic patients with fractures
improved their quality of life [27]. Baek et al. demonstrated that in
osteoporotic patients, the most important risk factors for new ver-
tebral compression fractures after the initial fracture is the degree
of osteoporosis and the altered biomechanics of the spine due to
spino-pelvic malalignment [28]. Furthermore, Iida et al. empha-
sized that the preservation of normal sagittal alignment in scoliotic
patients resulted in a prevalence of low back pain and quality of
life scores comparable to that of an age-matched general popula-
tion [29]. Jentzsch et al. stressed that underappreciating the sagittal
plane in the lumbar curve, mainly hyperlordosis, could lead to
increase facet joint arthritis [30].
By briey scanning the recent literature, one will notice the ris-
ing awareness of the signicance of sagittal alignment in various
spinal pathologies. The sagittal plane deserves respect whenever
one approaches the spine, from minor laminectomies to several
vertebral column osteotomies.
3.3. How to respect the sagittal plane when managing patients,
where to start from?
3.3.1. Proper imaging and standardized positioning
Radiographs are fundamental components of sagittal plane
analysis. Full 36 anteroposterior (AP) and lateral views showing
the femoral heads are crucial for a complete radiographic evalu-
ation of these patients [31]. Even better is a full body radiograph
that provides full visibility of the patients alignment and permits
the unmasking of all the compensatory mechanisms used to main-
tain an erect posture [32]. Regarding patient positioning, Horton
et al. reported that the free-standing position in the clavicle posi-
tion (elbows exed with the hands in a relaxed st, wrists exed,
and each ngertip centered in the ipsilateral supraclavicular fossae)
is the superior visualization method with minimal impact on the
natural stance of the patient, as compared to other positions [33].
Adopting a free standing position, without external support and
without instructing the patient to extend their knees or head, per-
mits not only the accurate quantication of sagittal malalignment
but also the investigation of compensatory mechanism recruit-
ment.
3.3.2. Assessment of the spino-pelvic harmony; PI minus LL
mismatch concept
Degenerative cascade could involve any focal or regional curves,
and a thorough assessment of the entire spine is highly benecial.
However, the loss of lumbar lordosis is one of the main drivers of
 B.G. Diebo et al. / Clinical Neurology and Neurosurgery 139 (2015) 295301
sagittal plane deterioration. In 2014, a study by Kim et al. demon-
strated that this loss is specic to the degenerated spine and not the
normal aging spine [34]. Because of the broad range of normative
values and the impact of pelvic morphology on spinal curvatures,
LL should always be assessed in relation to PI by utilizing PI-LL
methodology. Patients with a loss of LL of more than 10 in relation
to their pelvic incidence angle should undergo further clinical eval-
uation and assessment of daily functions/disability. In summary,
one should always begin by measuring PI, then LL, to ultimately
determine the mismatch.
3.3.3. Analysis of compensatory mechanisms
Compensatory mechanisms are the patients progressive
response to sagittal plane deterioration. Following a mild positive
sagittal malalignment, the patient often begins recruiting mecha-
nisms to compensate. These mechanisms often start in the exible
parts of the altered levels, progressing distally to the hip and
lower extremities [35]. Patients use these maneuvers to counter
the forward or backward translation of the Center of Mass (COM)
[17]. Initially, patients compensate by straightening the thoracic
spine [36], which requires muscular exertion. Subsequent notable
compensation tends to present with retroversion and posterior
translation of the pelvis, along with exion of the knees and ankles
[35,37,38].
3.4. Why is that signicant?
When a deformity or degenerative disease patient comes to the
clinic for assessment, the sagittal prole is already altered by both
the deformity and its compensation. For example, a post-operative
patient comes for evaluation after a L4-S1 lumbar fusion. It is crucial
to evaluate the unfused levels of the lumbar spine for the existence
of adjacent segment compensation to residual malalignment. As
mentioned above, if the fused segments were hypolordotic and
malaligned, the lumbar levels cephalad to the fusion will hyper-
extend to compensate and consequently increase lordosis in the
lumbar curve. This point might be overlooked and confused with
normal lumbar lordosis when measuring L1-S1 lordosis. Thus, it is
imperative to differentiate between malalignment and compensa-
tion.
Similarly, the assessment of pelvic tilt and knee exion is
important. These compensatory mechanisms regulate global spinal
malalignment and may mask an abnormal SVA. Hence, global spinal
alignment assessment alone is never enough and the evaluation of
PI-LL, PT and a glance at the lower limbs in a free standing position
should be considered. Pelvic tilt is a very sensitive marker of spino-
pelvic mismatch. If the measurement of SVA or PI-LL indicates
sagittal malalignment, then a normal PT should trigger concern and
may signal the existence of a hidden concomitant neurological or
muscular pathology [39]. Of note, patients with lumbar stenosis
may also present similarly, patient adopts a forward bending pos-
ture to relieve neural compression [40,41]. This is an attempt to
increase the volume of the central vertebral canal and the interver-
tebral foraminae. Finally, surgical intervention targets the action,
i.e. the drivers of malalignment. The compensatory mechanisms
are the counteraction and will be indirectly corrected following
rectication of the drivers of malalignment. However, a success-
ful realignment plan should not only restore the spino-pelvic
relationship, but it should also reset the compensatory mecha-
nisms, which are energy drainers and affect the patients quality
of life.
3.4.1. Global spinal alignment and gaze assessment
The progressive anterior translation of the head away from
the pelvis is quantied by the sagittal vertical axis (SVA) param-
eter [42]. SVA gives an idea about the general alignment of the
299
Table 1
Age-adjusted alignment targets.
Age group PT PI-LL SVA
<35 11.0 10.5 30.5
3544 15.4 4.6 5.5
4554 18.8 0.5 15.1
5564 22.0 5.8 35.8
6574 25.1 10.5 54.5
74 28.8 17.0 79.3
trunk and is the direct consequence to loss of LL despite pelvic
compensation by retroversion (increased PT) [43]. Thus, measure-
ment of spinopelvic parameters (PI-LL and PT), in addition to
SVA, provides a more comprehensive evaluation of sagittal spinal
alignment.
Finally, cervical spine involvement in compensatory mecha-
nisms aims at maintaining horizontal gaze by increasing cervical
lordosis in the setting of positive (i.e. anterior) alignment and a
decreasing cervical lordosis in the setting of negative (i.e. posterior)
alignment [44]. A study by Smith et al. revealed that the compen-
sation of cervical lordosis was found to be spontaneously corrected
following spinal realignment procedures [45]. Consequently, it is
important to determine if cervical lordosis is driven by underlying
thoracolumbar malalignment or if it is a part of spinal curvature
harmony.
4. Sagittal alignment targets: an update
Based on the tight relationship between sagittal plane deteri-
oration and quality of life measures, Schwab et al. incorporated
sagittal parameters into an adult spine deformity classication sys-
tem and determined cutoff values for the most clinically relevant
parameters in the sagittal prole (SVA, PI-LL, and PT) based upon
multi-center data [46]. Ideally, Schwab recommends a SVA <40 mm,
a PI-LL within 10 and a PT <20 as the targets for sagittal align-
ment. However, age-related changes occur in every part of the
musculo-skeletal complex as well as in the neuro-sensorial system
and must be accounted for. Schwab et al. investigated the impact of
age on spino-pelvic alignment in a study of more than 700 patients
[47]. Lafage et al. performed linear regression analysis of the radio-
graphic parameters (PT, PI-LL, and SVA) in relationship to age and
HRQOL (ODI and SF-36 PCS) to provide thresholds for radiographic
parameters in an age-stratied manner to present more patient
specic alignment thresholds. The data revealed that the ideal
sagittal alignment should account for age, with younger patients
requiring more rigorous alignment objectives [47] (Table 1).
5. Conclusion
Sagittal malalignment plays a respectable role in multiple if
not all spinal pathologies and therefore the benet of analyzing
sagittal alignment is not limited to deformity patients. While fur-
ther research is developing, the literature thus far reports a direct
relationship between sagittal alignment and patient-reported out-
comes in various spinal pathologies, attesting to the benet of
sagittal alignment analysis. The simplicity and generalized appli-
cability of the SRS-Schwab classication and its individualized
alignment goals offers a systematic, practical, and user-friendly
approach toward ensuring patient-tailored treatment and care.
Finally, the structural alignment of the spinal column and its radio-
graphic evaluation are only part of the full clinical work-up when
approaching deformity patients. Therefore, the dynamic aspects of
alignment, soft tissue analysis, and clinical evaluation are crucial in
managing these challenging conditions.
300 B.G. Diebo et al. / Clinical Neurology and Neurosurgery 139 (2015) 295301

References [23] S. Champain, Correlations Entre les Parametres Biomecaniques du Rachis et les
Indices Cliniques Pour lanalyse Quantitative des Pathologies du Rachis Lom-
baire et de Leur Traitement Chirurgical, cole Nationale Suprieure d Arts et
[1] J. Legaye, G. Duval-Beaupre, J. Hecquet, C. Marty, Pelvic incidence: a
Mtiers, 2008.
fundamental pelvic parameter for three-dimensional regulation of spinal
[24] B. Blondel, F.J. Schwab, B. Ungar, J.S. Smith, K.H. Bridwell, S.D. Glassman,
sagittal curves, Eur. Spine J. 7 (1998) 99103, http://dx.doi.org/10.1007/
et al., Impact of magnitude and percentage of global sagittal plane correc-
s005860050038.
tion on health-related quality of life at 2-years follow-up, Neurosurgery
[2] G. Duval-Beaupre, C. Schmidt, P. Cosson, A barycentremetric study of the
71 (2012) 341348, http://dx.doi.org/10.1227/NEU.0b013e31825d20c0,
sagittal shape of spine and pelvis: the conditions required for an economic
Discussion 348.
standing position, Ann. Biomed. Eng. 20 (1992) 451462, http://dx.doi.org/10.
[25] J.S. Smith, E. Klineberg, F. Schwab, C.I. Shaffrey, B. Moal, C.P. Ames, et al., Change
1007/BF02368136.
in classication grade by the SRS-Schwab adult spinal deformity classication
[3] P. Mangione, D. Gomez, J. Senegas, Study of the course of the incidence angle
predicts impact on health-related quality of life measures: prospective analy-
during growth, Eur. Spine J. 6 (1997) 163167.
sis of operative and non-operative treatment, Spine (Phila Pa 1976) 38 (2013)
[4] R. Vialle, N. Levassor, L. Rillardon, A. Templier, W. Skalli, P. Guigui, Radiographic
16631671, http://dx.doi.org/10.1097/BRS.0b013e31829ec563.
analysis of the sagittal alignment and balance of the spine in asymptomatic
[26] M. Kumar, A. Baklanov, D. Chopin, Correlation between sagittal plane changes
subjects, J. Bone Joint Surg. Am. 87 (2005) 260267, http://dx.doi.org/10.2106/
and adjacent segment degeneration following lumbar spine fusion, Eur. Spine
JBJS.D.02043.
J. 10 (2001) 314319, http://dx.doi.org/10.1007/s005860000239.
[5] F.J. Schwab, A. Patel, B. Ungar, J. Farcy, V. Lafage, Adult spinal deformity-
[27] N. Miyakoshi, M. Hongo, T. Kobayashi, T. Abe, E. Abe, Y. Shimada, Improve-
postoperative standing imbalance: how much can you tolerate? An overview
ment of spinal alignment and quality of life after corrective surgery for spinal
of key parameters in assessing alignment and planning corrective surgery,
kyphosis in patients with osteoporosis: a comparative study with non-operated
Spine (Phila Pa 1976) 35 (2010) 22242231, http://dx.doi.org/10.1097/BRS.
patients, Osteoporos. Int. (2015), http://dx.doi.org/10.1007/s00198-015-3163-
0b013e3181ee6bd4.
5.
[6] F.J. Schwab, B. Blondel, S. Bess, R. Hostin, C.I. Shaffrey, J.S. Smith, et al., Radio-
[28] S.-W. Baek, C. Kim, H. Chang, The relationship between the spinopelvic balance
graphical spinopelvic parameters and disability in the setting of adult spinal
and the incidence of adjacent vertebral fractures following percutaneous ver-
deformity: a prospective multicenter analysis, Spine (Phila Pa 1976) 38 (2013)
tebroplasty, Osteoporos. Int. 26 (2015) 15071513, http://dx.doi.org/10.1007/
E803E812, http://dx.doi.org/10.1097/BRS.0b013e318292b7b9.
s00198-014-3021-x.
[7] F.J. Schwab, B. Ungar, B. Blondel, J. Buchowski, J. Coe, D. Deinlein, et al., Scoliosis
[29] T. Iida, N. Suzuki, K. Kono, Y. Ohyama, J. Imura, A. Ato, et al., Minimum
Research Society Schwab adult spinal deformity classication: a validation
20 years long-term clinical outcome after spinal fusion and instrumentation
study, Spine (Phila Pa 1976) 37 (2012) 10771082, http://dx.doi.org/10.1097/
for scoliosis, Spine (Phila Pa 1976) 1 (2015), http://dx.doi.org/10.1097/BRS.
BRS.0b013e31823e15e2.
0000000000000991.
[8] F.J. Schwab, B.G. Diebo, J.S. Smith, R.a. Hostin, C.I. Shaffrey, M.E. Cunningham,
[30] T. Jentzsch, J. Geiger, M.a Knig, C.M.L. Werner, Hyperlordosis is associated with
et al., Fine-tuned surgical planning in adult spinal deformity: determining the
facet joint pathology at the lower lumbar spine, J. Spinal Disord. Tech. (2013),
lumbar lordosis necessary by accounting for both thoracic kyphosis and pelvic
http://dx.doi.org/10.1097/BSD.0b013e3182aab266.
incidence, Spine J. 14 (2014) S73, http://dx.doi.org/10.1016/j.spinee.2014.08.
[31] J.S. Smith, C.I. Shaffrey, V. Lafage, F.J. Schwab, R. Haid, T.S. Protopsaltis,
189.
et al., Assessment of impact of long-cassette standing X-rays on surgical
[9] J. Cobb, Outline for the study of scoliosis, Instr. Course Lect. Am. Acad. Orthop.
planning for lumbar pathology: an international survey of spine sur-
Surg. (Ann Arbor, Michigan) (1948) 261.
geons, in: Int. Meet. Adv. Spine Tech. (IMAST), 1619 July, Valencia, Spain,
[10] P. Roussouly, S. Gollogly, E. Berthonnaud, J. Dimnet, Classication of the normal
2014.
variation in the sagittal alignment of the human lumbar spine and pelvis in
[32] S. Deschnes, G. Charron, G. Beaudoin, H. Labelle, J. Dubois, M.-C. Miron, et al.,
the standing position, Spine (Phila Pa 1976) 30 (2005) 346353, 00007632-
Diagnostic imaging of spinal deformities: reducing patients radiation dose with
200502010-00016 [PII].
a new slot-scanning X-ray imager, Spine (Phila Pa 1976) 35 (2010) 989994,
[11] M. Kozanek, S. Wang, P.G. Passias, Q. Xia, G.G. Li, C.M. Bono, et al., Range
http://dx.doi.org/10.1097/BRS.0b013e3181bdcaa4.
of motion and orientation of the lumbar facet joints in vivo, Spine
[33] W.C. Horton, C.W. Brown, K.H. Bridwell, S.D. Glassman, S.-I. Suk, C.W. Cha,
(Phila Pa 1976) 34 (2009) E689E696, http://dx.doi.org/10.1097/BRS.
Is there an optimal patient stance for obtaining a lateral 36 radiograph?
0b013e3181ab4456.
A critical comparison of three techniques, Spine (Phila Pa 1976) 30 (2005)
[12] E.H. Boseker, J.H. Moe, R.B. Winter, S.E. Koop, Determination of normal tho-
427433.
racic kyphosis: a roentgenographic study of 121 normal children, J. Pediatr.
[34] Y.B. Kim, Y.J. Kim, Y.-J. Ahn, G.-B. Kang, J.-H. Yang, H. Lim, et al., A comparative
Orthop. 20 (2000) 796798.
analysis of sagittal spinopelvic alignment between young and old men without
[13] A. Faline, S. Szadkowski, E. Berthonnaud, V. Fiere, P. Roussouly, Morphological
localized disc degeneration, Eur. Spine J. 23 (2014) 14001406, http://dx.doi.
Study of the Lower Cervical Curvature: Results of 230 Asymptomatic Subjects,
org/10.1007/s00586-014-3236-8.
EuroSpine, Brussels, Belgium, 2007.
[35] I. Obeid, O. Hauger, S. Aunoble, A. Bourghli, N. Pellet, J.-M. Vital, Global analy-
[14] J.C. Le Huec, H. Demezon, S. Aunoble, Sagittal parameters of global cervical
sis of sagittal spinal alignment in major deformities: correlation between lack
balance using EOS imaging: normative values from a prospective cohort of
of lumbar lordosis and exion of the knee, Eur. Spine J. 20 (Suppl. 5) (2011)
asymptomatic volunteers, Eur. Spine J. 24 (2014) 6371, http://dx.doi.org/10.
681685, http://dx.doi.org/10.1007/s00586-011-1936-x.
1007/s00586-014-3632-0.
[36] N. Aurouer, I. Obeid, O. Gille, V. Pointillart, J.-M. Vital, Computerized preoper-
[15] J.C. Le Huec, S. Aunoble, L. Philippe, P. Nicolas, Pelvic parameters: origin and
ative planning for correction of sagittal deformity of the spine, Surg. Radiol.
signicance, Eur. Spine J. (2011) 18.
Anat. 31 (2009) 781792, http://dx.doi.org/10.1007/s00276-009-0524-9.
[16] F.J. Schwab, V. Lafage, R. Boyce, W. Skalli, J-P.P. Farcy, Gravity line analysis in
[37] B.G. Diebo, E. Ferrero, R. Lafage, V. Challier, B. Liabaud, S. Liu, et al., Recruit-
adult volunteers: age-related correlation with spinal parameters, pelvic param-
ment of compensatory mechanisms in sagittal spinal malalignment is age and
eters, and foot position, Spine (Phila Pa 1976) 31 (2006) E959E967, http://dx.
regional deformity dependent: a full-standing axis analysis of key radiograph-
doi.org/10.1097/01.brs.0000248126.96737.0f.
ical parameters, Spine (Phila Pa 1976) 40 (2015) 642649, http://dx.doi.org/10.
[17] V. Lafage, F.J. Schwab, W. Skalli, N. Hawkinson, P.-M. Gagey, S. Ondra, et al.,
1097/BRS.0000000000000844.
Standing balance and sagittal plane spinal deformity: analysis of spinopelvic
[38] C.C. Barrey, P. Roussouly, Le Huec J-CC, G. DAcunzi, G. Perrin, Compensatory
and gravity line parameters, Spine (Phila Pa 1976) 33 (2008) 15721578, http://
mechanisms contributing to keep the sagittal balance of the spine, Eur. Spine J.
dx.doi.org/10.1097/BRS.0b013e31817886a2.
22 (Suppl. 6) (2013) S834S841, http://dx.doi.org/10.1007/s00586-013-3030-
[18] F. Schwab, A. Patel, B. Ungar, J. Farcy, V. Lafage, Adult spinal deformity-
z.
postoperative standing imbalance: how much can you tolerate? An overview
[39] V. Lafage, F.J. Schwab, A. Patel, N. Hawkinson, J-P. Farcy, Pelvic tilt and truncal
of key parameters in assessing alignment and planning corrective surgery,
inclination: two key radiographic parameters in the setting of adults with spinal
Spine (Phila Pa 1976) 35 (2010) 22242231, http://dx.doi.org/10.1097/BRS.
deformity, Spine (Phila Pa 1976) 34 (2009) E599E606, http://dx.doi.org/10.
0b013e3181ee6bd4.
1097/BRS.0b013e3181aad219.
[19] F.J. Schwab, V. Lafage, J.-P. Farcy, K.H. Bridwell, S.D. Glassman, S. Ondra, et al.,
[40] J.K. Lim, S.M. Kim, Comparison of sagittal spinopelvic alignment between lum-
Surgical rates and operative outcome analysis in thoracolumbar and lumbar
bar degenerative spondylolisthesis and degenerative spinal stenosis, J. Korean
major adult scoliosis: application of the new adult deformity classication,
Neurosurg. Soc. 55 (2014) 331336, http://dx.doi.org/10.3340/jkns.2014.55.6.
Spine (Phila Pa 1976) 32 (2007) 27232730, http://dx.doi.org/10.1097/BRS.
331.
0b013e31815a58f2.
[41] H. Suzuki, K. Endo, H. Kobayashi, H. Tanaka, K. Yamamoto, Total sagittal spinal
[20] J.A. Youssef, D.O. Orndorff, C.A. Patty, M.A. Scott, H.L. Price, L.F. Hamlin, et al.,
alignment in patients with lumbar canal stenosis accompanied by intermittent
Current status of adult spinal deformity, Glob. Spine J. 3 (2013) 5162, http://
claudication, Spine (Phila Pa 1976) 35 (2010) E344E346, http://dx.doi.org/10.
dx.doi.org/10.1055/s-0032-1326950.
1097/BRS.0b013e3181c91121.
[21] J. Terran, F. Schwab, C.I. Shaffrey, J.S. Smith, P. Devos, C.P. Ames, et al.,
[42] R.P. Jackson, A.C. McManus, Radiographic analysis of sagittal plane alignment
The SRS-schwab adult spinal deformity classication: assessment and
and balance in standing volunteers and patients with low back pain matched
clinical correlations based on a prospective operative and nonoperative
for age, sex, and size. A prospective controlled clinical study, Spine (Phila Pa
cohort, Neurosurgery 73 (2013) 559568, http://dx.doi.org/10.1227/NEU.
1976) 19 (1994) 16111618.
0000000000000012.
[43] S.D. Glassman, S. Berven, K. Bridwell, W. Horton, J.R. Dimar, Correlation of
[22] D. Nielsen, L. Hansen, C. Dragsted, M. Gehrchen, B. Dahl, Clinical correlation
radiographic parameters and clinical symptoms in adult scoliosis, Spine (Phila
of SRS-Schwab classication with HRQOL measures in a prospective non-US
Pa 1976) 30 (2005) 682688, http://dx.doi.org/10.1097/01.brs.0000155425.
cohort of ASD patients, in: Int. Meet. Adv. Spine Tech. (IMAST), July 1619,
04536.f7.
Valencia, Spain, 2014.
 B.G. Diebo et al. / Clinical Neurology and Neurosurgery 139 (2015) 295301 301

[44] B. Blondel, F.J. Schwab, S. Bess, C.P. Ames, P.V. Mummaneni, R. Hart, et al.,
Posterior global malalignment after osteotomy for sagittal plane deformity:
it happens and here is why, Spine (Phila Pa 1976) 38 (2013) E394E401, http://
dx.doi.org/10.1097/BRS.0b013e3182872415.
[45] J.S. Smith, C.I. Shaffrey, V. Lafage, B. Blondel, F.J. Schwab, R. Hostin, et al., Spon-
taneous improvement of cervical alignment after correction of global sagittal
balance following pedicle subtraction osteotomy, J. Neurosurg. Spine 17 (2012)
300307, http://dx.doi.org/10.3171/2012.6.SPINE1250.
[46] F. Schwab, B. Ungar, B. Blondel, J. Buchowski, J. Coe, D. Deinlein,
et al., SRS-Schwab adult spinal deformity classication: a validation study,
Spine (Phila Pa 1976) 37 (2012) 10771082, http://dx.doi.org/10.1097/BRS.
0b013e31823e15e2.
[47] F.J. Schwab, R. Lafage, B.B. Liabaud, B.G. Diebo, J.S. Smith, R.A. Hostin, et al., Does
one size t all? Dening spinopelvic alignment thresholds based on age, Spine
J. 14 (2014) S120S121, http://dx.doi.org/10.1016/j.spinee.2014.08.299.